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* x...21 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 , E P O BOX 2009, STOCKTON, CA 95201 �• � PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address ✓ City Size/Acreage Owner's Name ddress ? `s Phone 3�& —Q' Contractor dress License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DE ION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER O Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTU ELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL P R 0 B LpkAl EA CONSTRUCTION SPECIFICATIONS L-] Industrial ❑ Open Bottom anteca Dia. of Well Excavation Dia. of Well Casing [.I Domestic/Private ❑ Gravel P ❑ Tracy Type of Casing- ['I Public Cl er (-1 Delta Depth of Grout Seal Type of Grout 11 Irrigation �.Approx. Depth I I Eastern Surface Seal Installed by ^ Repair Wo ne I] Type of Pump H.P. State Work Done _ Qom/ We struction ❑ We11 Diameter Sealing Material & Depth Depth Filler Material & Depth ; I� TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION (No septic system permitted if public sewer is ' available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of soil to adept f 3 feet: Water table depth SEPTIC TANK �ype/Mfg ?� Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well t Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nes I Foundation Property Line SEEPAGE PITS 11 Depth ize _ Number SUMPS LI Distance to Weare Well Foundation Property Line DISPOSAL PONDS ❑ 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin county Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall employ persons subject to workman's compensa- tion laws of California." The applica t at call for all req 'ed i ctions. Complete drawingo rev rse side. Signed X Title: Date: ✓ f U �1`�- FOR DEPARTMENT USE ONLY Application Accepted by ` i Date �d�— Area Pit or Grout Inspection by� Date Final Inspection by Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. INFO aa qg . EM 3-24(REV.1s 19 1.2EH1 (S -Ab�-